Non-compliance follow-up·March 28, 2024

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:45AM to conduct a non-compliance inspection. LPA followed up on the following areas which were initially addressed during a non-compliance meeting dated 07/21/2021. LPA met with Executive Director, Ric Pielstick. Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. LPA observed medications to be double locked in medication room. LPA and Health Services Director (HSD) toured the Memory Care unit and conducted an inspection of 3 residents apartments. 3 of 3 apartments did not contain any unlocked medications. Prohibited Conditions: Facility retained a resident with a prohibited condition. LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 0 of 6 resident files reviewed contained evidence of a resident being retained with a prohibited health condition. Timely Medical Attention: Facility failed to seek timely medical attention. LPA reviewed incident reports and confirmed that facility has been seeking timely medical attention. Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 6 of 6 files had medical assessments completed as required per regulation. Continued on LIC809C Continued from LIC809 Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPA reviewed a sample of 3 Memory Care and 3 Assisted Living files. 1 of 6 files reviewed did not have a pre-admission appraisal. Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA reviewed LIC500 Personnel Report as well as facilities employee roster which indicates which department each individual works in. LPA confirmed with Memory Care Director that there are 4-5 Caregivers on shift during AM and PM shifts, as well as 2 Medication Technicians, and at least 4 NOC shift throughout the facility. Facility Food Services: Facility kitchen area was toured by LPA and Business Office Director. LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. LPA reviewed regulation 87211 with HSD and discussed the importance of reporting accurately and within seven days as required per regulation. LPA reviewed incident reports and confirmed that there were four incident reports received since October of 2023 that were received by CCL past the required seven day limit. No deficiencies cited during inspection.